Respiratory Distress/Critical Airway

1. Respiratory Distress/Critical Airway Deb Updegraff, RN, CCRN Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit

2. Signs of Respiratory Distress • Tachypnea • Tachycardia • Grunting • Stridor • Head bobbing • Flaring • Inability to lie down • Agitation

3. Continued- Signs and Symptoms of Respiratory Distress • Retractions • Use of Accessory muscles • Wheezing • Sweating • Prolonged expiration • Pulsus paradoxus • Apnea • Cyanosis

4. Causes of Resp Distress • Infections Pneumonias Bronchiolitis Empyemas

5. Causes Cont. • Excessive fluid in the lung Pulmonary edema (CHF) • Excessive fluid or air in the pleural space Pneumothorax, pleural effusions • Upper airway obstructions swollen airway, large tonsils, malacias, • Lower airway obstructions asthma

8. Interventions • Comfort measures • Patient position • O2 • Diuretics • Broncho-dialators • Nasal trumpet • Positive Pressure • Chest tube • Intubation

9. The Pediatric Airway • Introduction • Anatomy / Physiology • Positioning • Adjuncts • Intubation

10. Anatomy : Tongue • Large • Loss of tone with sleep, sedation, CNS dysfunction • Frequent cause of upper airway obstruction

11. Anatomy : Larynx • High position • Infant : C 1 • 6 months: C 3 • Adult: C 5-6 • Anterior position

12. Children are different Photos : Calvin Kuan

13. Anatomy : Epiglottis • Relatively large size in children • Omega shaped • Floppy – not much cartilage

14. Airway Positioning “Sniffing Position” In the child older than 2 years Towel is placed under the head Photos: Calvin Kuan

15. Photo: Calvin Kuan

16. Airway positioning for children <2yrs Photo: Calvin Kuan

17. Photo: Calvin Kuan

18. Airway adjuncts • Nasal airway • Oral airway

19. Adjuncts: Oral Airway Correct size Photo: Calvin Kuan

20. Nasopharyngeal Airway Length: Nostril to Tragus Contraindications: • Basilar skull fracture • CSF leak • Coagulopathy Photo: Calvin Kuan

21. Endotracheal tube as nasal airway A regular ETT can be cut and used as a nasal airway Photo: Calvin Kuan

22. Intubation: Indications • Failure to oxygenate • Failure to remove CO2 • Increased WOB • Neuromuscular weakness • CNS failure • Cardiovascular failure

23. Laryngoscope Blades Macintosh Miller Photo: Calvin Kuan

24. Intubation Technique Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis Photo: Calvin Kuan

25. Intubation Technique Better in older children who have a stiff epiglottis Curved Laryngoscope Blade – placed in the vallecula Slide: Calvin Kuan

26. Anatomy : Larynx Narrowest point = cricoid cartilage in the child Photo: Calvin Kuan

27. Intubation Age kg ETT Length (lip) Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 Children > 2 years: ETT size: Age/4 + 4 ETT depth (lip): Age/2 + 12 Slide: Calvin Kuan

28. Technique: Intubation How far does it go in ? Photo: Calvin Kuan

29. Critical Airway

30. An Airway is designated CRITICAL by any of the following Criteria • Airway status post reconstruction surgery • Difficult airway in the OR per anesthesia • Patients with syndromes recognized with difficult airways • Micrognathia- Pierre Robin, Treacher Collins • Cervical Spine abnormalitieS • Goldenhars, Klipper-Fiell • Macroglossia • Beckwith-Wiedemann, Downs, Achondroplasia • Soft tissue abnormalities • Submandiibular masses, epiglottis, hemangiiomas

31. Treacher Collins

33. Treacher Collins After Mandibular Distraction Before Mandibular Distraction

34. Hemangioma

36. Pierre Robin

37. Goldenhar

39. Airway Reconstructive Surgery- Very Common Critical Airway patient in the PICU Subglottic stenosis is a narrowing of subglottic airway housed In the cricoid cartilage. This is the narrowest area in the pediatric airway.

40. Normal view of trachea

41. 4 month old with acquired Grade III Subglottic stenosis from intubation

42. Same view: Magnified

43. Following Cricoid Split Surgical Procedure

44. Preoperative Subglottic View of 2 year old with acquired verticle subglottic stenosis

45. After anterior and posterior grafting and successful decannulation of tracheostomy

46. ICU Check list for Critical Airway: Patient’s Weight: Patient’s name: • -Room ready with intubation box. • -Critical Airway sign posted at HOB. • -Continuous infusion meds ordered (i.e. benzodiazepines • , Opioids, muscle relaxants, and others). • -Antibiotics and anti-reflux meds ordered. • Sign-out has occurred and is documented. • -ET tube is secured. • -Chest x-ray obtained which is used to determine where the ET tube and CVL are located. • Patient to have arm restraintsordered and placed. • Code Pack in the room. • Code sheet completed in the room. • My Doctor sheet completed and at the head of the bed.